Improving Head CT Scan Decisions for Pediatric Minor Head Trauma in General Emergency Departments: A Pragmatic Implementation Study - 21/09/22
, Doug Wolfe, MBA a, Angelene Hunt, MSN a, Allison Neeley, MBA a, Neer Shrestha, MS a, Steven Hess, BS a, James Hellewell, MD, MS a, Gregory Snow, PhD a, Rajendu Srivastava, MD, MPH a, b, Douglas Nelson, MD a, b, Jeff E. Schunk, MD bAbstract |
Study objective |
To measure the effectiveness of a multimodal strategy, including simultaneous implementation of a clinical decision support system, to sustain adherence to a clinical pathway for care of children with minor head trauma treated in general emergency departments (EDs).
Methods |
Prospective, type III hybrid effectiveness-implementation cohort study with a nonrandomized stepped-wedge design and monthly repeated site measures. The study population included pediatric minor head trauma encounters from July 2018 to December 2020 at 21 urban and rural general ED sites in an integrated health care system. Sites received the intervention in 1 of 2 steps, with each site providing control and intervention observations. Measures included guideline adherence, the computed tomography (CT) scan rate, and 72-hour readmissions with clinically important traumatic brain injury. Analysis was performed using multilevel hierarchical modeling with random intercepts for the site and physician.
Results |
During the study, 12,670 pediatric minor head trauma encounters were cared for by 339 clinicians. The implementation of the clinical pathway resulted in higher odds of guideline adherence (adjusted odds ratio 1.12 [95% confidence interval 1.03 to 1.22]) and lower odds of a CT scan (adjusted odds ratio 0.96 [95% confidence interval 0.93 to 0.98]) in intervention versus control months. Absolute risk difference was observed in both guideline adherence (site median: +2.3% improvement) and the CT scan rate (site median: −6.6% reduction). No 72-hour readmissions with confirmed clinically important traumatic brain injury were identified.
Conclusion |
Implementation of a minor head trauma clinical pathway using a multimodal approach, including a clinical decision support system, led to sustained improvements in adherence and a modest, yet safe, reduction in CT scans among generally low-risk patients in diverse general EDs.
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| Please see page 333 for the Editor’s Capsule Summary of this article. |
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| Supervising editor: Lise E. Nigrovic, MD, MPH. Specific detailed information about possible conflict of interest for individual editors is available at editors. |
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| Author contributions: JES, AJK, RS, and DW conceived and designed the study and obtained internal funding. DN, JH, NS, and SH supervised technology intervention development and deployment. JES, DW, and AH supervised the conduct of the study and undertook recruitment of participating sites and data collection. AN managed the data, including data quality control. AJK and GS provided statistical advice on study design and analyzed the data. AJK drafted the manuscript, and all authors contributed substantially to its revision and approved the final submission. JES takes final responsibility for the paper as a whole. |
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| All authors attest to meeting the four ICMJE.org authorship criteria: (1) Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND (2) Drafting the work or revising it critically for important intellectual content; AND (3) Final approval of the version to be published; AND (4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. |
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| Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). Dr Knighton holds shares in a large publicly traded health care organization, recently completed work as a venous thromboembolism guideline development methodologist for the American College of Chest Physicians, and received additional support from the National Center for Advancing Translational Sciences of the National Institutes of Health (KL2TR002539). The funding body was not involved in the study and collection, analysis or interpretation of the data, or in writing the manuscript. Dr Srivastava is a physician founder of the IPASS Patient Safety Institute and his equity is owned by his employer, Intermountain Healthcare. |
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| Funding and support: Funding for this research was provided by the operating funds of Intermountain Healthcare. |
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| Preliminary results presented at the Academy Health Annual Meeting, June 15, 2021 (Virtual). |
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Vol 80 - N° 4
P. 332-343 - octobre 2022 Retour au numéro
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